■ Researchers say studying the alternative steps that physicians take when using their health IT systems will help improve future versions of electronic health records.

Improved efficiency was one promise that proponents of electronic health record systems often touted to physicians to persuade them to adopt the systems. But many doctors have found the only way they can accomplish certain tasks in a reasonable amount of time is to do them on paper.

A study published online March 14 in the Journal of the American Medical Informatics Assn. measured the extent to which 11 primary care practices use so-called workarounds instead of their EHRs. Researchers found 10 of 11 paper-based workarounds identified in previous studies were being used. The three most consistent reasons for the paper-based approach were efficiency, memory and awareness.

Researchers observed 120 clinical staff members at the 11 practices, which were part of three larger health care organizations, to determine how and when they turned to paper to accomplish certain tasks. Each organization had an EHR system designed in-house that had been in use for several years. But despite all three health systems using different EHRs, and the presumed tailoring done to each EHR to fit an organization's needs, the researchers found many of the same workarounds at all 11 sites.

One common workaround was to write patient vitals on paper instead of entering them in the EHR if the person responsible for entering the data was unavailable. Another was using paper-based reminders to accomplish a task (i.e., Post-it notes). Also common were paper-based reminders alerting co-workers of new or important information that was added to a patient's record.

“Understanding the reasons for workarounds is important to facilitate user-centered design and alignment between work context and available health information technology tools,” the study's authors wrote.

Even though the EHRs examined are not commercial, the same problems probably exist in commercial systems, said study co-author Jason Saleem, PhD, a research investigator with VA Health Services' research and development team.

“A lot of these systems may be designed by nonclinicians who don't have a good understanding of clinical work,” Saleem said. They may be designed by superusers, not the typical clinician who needs to use the tools. “What works for a superuser clinician who is into informatics and designing these systems might be completely different from the average clinician.”

Marc Hafer, CEO of Simpler Consulting, said the people who use the systems should be involved in the design and selection. His company provides health IT consulting services to practices using the Toyota “lean management” technique, which focuses on eliminating waste and increasing efficiencies.

Making systems more usable

EHR usability has been on the radar of vendors in recent months. It has been blamed for growing dissatisfaction among EHR users and has caused many to scrap the systems they have for newer ones that are easier to use.

Usability is a measurable criterion that will be included in the certification process that EHR vendors must go through to have their system approved for stage 2 of the meaningful use incentive program. The federal program pays physicians up to $44,000 from Medicare or nearly $64,000 from Medicaid for the adoption and meaningful use of EHRs.

Saleem said he hopes some workaround issues will be resolved now that more attention is being paid to usability. But beyond usability, integrating the systems into natural work flow continues to be a problem. Studying workarounds will provide insight into what the next EHR iterations should look like, he said.

Hafer said work flow should be analyzed before shopping for an EHR. Work flow should be redesigned so that any waste is eliminated, then specifications can be written. However, the way a practice operates is always changing, he added. Therefore, practices must look for systems with the flexibility to grow and change with the practices' and users' needs.

Saleem, whose PhD training was in “human factors engineering,” said part of his motivation for studying this issue was a realization he made as he looked around his office.

“My office is littered with paper reminders and Post-it notes,” he said. “I use electronic systems, but I use paper, too. There's just something about having a paper Post-it note that is superior to having a similar reminder in a computer. It's right there in front of you — you don't have to log in and find your task list. That's hard to replicate with an electronic system.

“If an electronic system doesn't match the preferred or most efficient work flow that the clinician is used to using, then you're definitely going to see a workaround there.”

Hafer said these types of workarounds cause variations to what should be standardized work. “Variations create waste,” he said.

When the preferences of people using workarounds are included in the design process, or in efforts to tweak the systems, “the EHR becomes something they believe in,” he said.

ADDITIONAL INFORMATION

11 reasons behind paper workarounds for EHRs

A 2009 study in the International Journal of Medical Informatics identified 11 categories where medical practices used paper instead of electronic health record systems:

Efficiency: Paper use enhanced actual or perceived efficiencies.

Knowledge/skill/ease of use: Clinicians' knowledge of a particular system or computer skills in general were lacking, or the systems were not easy to use.

Memory: Paper was used as a reminder or alert involving information within the system.

Sensorimotor preferences: Some users had personal preferences to “hear” something (i.e., a file being dropped in a basket) or have something tangible that can be delivered or manipulated (i.e., handwritten notes).

Awareness: Paper was used to make another clinician aware of new information.

Task specificity: Paper enhanced the ability to customize data to a patient, group of individuals, clinicians or departments (i.e., printed test results for a specific group).

Task complexity: A complicated task was not supported by the health IT system.

Data organization: Electronic data were not displayed in an organized or efficient manner.

Longitudinal data processes: Paper was used to track certain data metrics to look for trends.

Trust: Users believed that paper provides “proof.”

Security: Electronic system was not secure, so paper printouts were used.

Source: “Exploring the persistence of paper with the electronic health record,” International Journal of Medical Informatics, September 2009 (link)